Schizophrenia

By Maria Theresa M.
Herbolingo

Definition
fundamental and
characteristic
distortions of thinking
and perception, and
affects that are
inappropriate or
blunted.
Clear consciousness
and intellectual
capacity are usually
maintained although
certain cognitive
deficits may evolve in
the course of time.

contd
The most important
psychopathological
phenomena include
thought echo
thought insertion or
withdrawal
thought broadcasting
delusional perception and
delusions of control
influence or passivity
hallucinatory voices
commenting or discussing the
patient in the third person
thought disorders and
negative symptoms.

Schizophrenia
Schizophrenia occurs with regular
frequency nearly everywhere in the world
in 1 % of population and begins mainly in
young age (mostly around 16 to 25 years).
Schizophrenia is defined by
a group of characteristic positive and
negative symptoms
deterioration in social, occupational, or
interpersonal relationships
continuous signs of the disturbance for
at least 6 months

History
Emil Kraepelin: This illness
develops relatively early in life,
and its course is likely
deteriorating and chronic;
deterioration reminded dementia
(Dementia praecox), but was not
followed by any organic changes
of the brain, detectable at that
time.
Eugen Bleuler: He renamed
Kraepelins dementia praecox as
schizophrenia (1911); he
recognized the cognitive
impairment in this illness, which
he named as a splitting of mind.
Kurt Schneider: He emphasized
the role of psychotic symptoms, as
hallucinations, delusions and gave
them the privilege of the first
rank symptoms even in the
concept of the diagnosis of
schizophrenia.

4 A (Bleuler)

Bleuler maintained, that for the diagnosis of

schizophrenia are most important the following four
fundamental symptoms:

affective blunting
disturbance of association (fragmented thinking)
autism
ambivalence (fragmented emotional response)

These groups of symptoms, are called four A s

and Bleuler thought, that they are primary for this
diagnosis.
The other known symptoms, hallucinations,
delusions, which are appearing in schizophrenia very
often also, he used to call as a secondary
symptoms, because they could be seen in any
other psychotic disease, which are caused by quite
different factors from intoxication to infection or
other disease entities.

Course
of Illness

Course of schizophrenia:
continuous without
temporary improvement
episodic with progressive
or stable deficit
episodic with complete
or incomplete remission
Typical stages of
schizophrenia:
prodromal phase
active phase
residual phase

Clinical Picture

Diagnostic manuals:

lCD-10 (International Classification of

Disease, WHO)
DSM-IV (Diagnostic and Statistical
Manual, APA)

Clinical picture of schizophrenia is

according to lCD-10, defined from the
point of view of the presence and
expression of primary and/or secondary
symptoms (at present covered by the
terms negative and positive symptoms):
the negative symptoms are represented by
cognitive disorders, having its origin
probably in the disorders of associations of
thoughts, combined with emotional blunting
and small or missing production of
hallucinations and delusions
the positive symptom are characterized by
the presence of hallucinations and delusions
the division is not quite strict and lesser or
greater mixture of symptoms from these two
groups are possible

Positive and Negative

Symptoms

Negative

Positive

Alogia

Hallucinations

Affective flattening

Delusions

Avolition-apathy

Bizarre behaviour

Anhedonia-asociality

Positive formal thought

disorder

Attentional impairment

Positive symtoms
Those that appear to reflect an excess or
distortion of normal functions. Positive
symptoms are those that have a positive
reaction from some treatment. In other
words, positive symptoms respond to
treatment.
Delusions. Those where the patient thinks
he is being followed or watched are
common; also the belief that people on TV,
radio are directing special messages to
him/her.

 Hallucinations. Distortions or
exaggerations of perception in any of
the senses.
Often they hear voices within their
own thoughts followed by visual
hallucinations.

 Disorganized thinking/speech.
AKA loose associations; speech is
tangential, loosely associated or
incoherent enough to impair
communication.

Grossly disorganized behavior.

Difficulty in goal directed behavior (ADLs), unpredictable agitation
or silliness, social disinhibition, or bizarre behavior.

There is a purposelessness to behavior.

 Catatonic behavior.
Marked decrease in reaction to
immediate environment, sometimes
just unaware of surroundings, rigid or
bizarre postures, aimless motor
activity.

 Inappropriate response to stimuli

Unusual motor behavior (pacing,
rocking)
Depersonalization
Derealization
Somatic preoccupations

Negative Symptoms
Those that appear to reflect a
diminution or loss of normal functions.
May be difficult to evaluate because
they are not as grossly abnormal as
positive symptoms.
Currently there is no treatment that has
a consistent impact on negative
symptoms

 Affective flattening.
Reduction in the range and intensity
of emotional expression, including
facial expression, voice tone, eye
contact and body language.

 Alogia (poverty of speech)

Lessening of speech fluency and
productivity, thought to reflect
slowing or blocked thoughts; often
manifested as short, empty replies to
questions.

 Avolition
The reduction, difficulty or inability to
initiate and persist in goal-directed
behavior. Often mistaken for
apparent disinterest.

 No longer interested in going out

with friends
No longer interested in activities that
the person used to show enthusiasm
No longer interested in anything
Sitting in the house for hours or days
doing nothing

Disorganized Symptoms
This one is somewhat new and may
not be considered valid.
It is thought disorder, confusion,
disorientation and memory problems.

Cognitive Symptoms
Difficulties in concentration and
memory:
Disorganized thinking
Slow thinking
Difficulty understanding
Poor concentration
Poor memory
Difficulty expressing thoughts
Difficulty integrating thoughts, feelings,
behaviors

The Criteria of Diagnosis

For the diagnosis of schizophrenia
a) presence of one very clear
symptom - from point a) to d) the
hearing of own thoughts, the
feelings of thought withdrawal,
thought insertion, or thought
broadcasting
b) the delusions of control, outside
manipulation and influence, or the
feelings of passivity, which are
connected with the movements of
the body or extremities, specific
thoughts, acting or feelings,
delusional perception

COND
C]
hallucinated voices,
commenting
permanently the
behavior of the
patient or they talk
about him between
themselves, or the
other types of
hallucinatory voices,
coming from
different parts of
body.
D]
permanent delusions
of different kind,
which are
inappropriate and
unacceptable in
given culture

F20-F29 Schizophrenia, Schizotypal

and Delusional Disorders

F20
Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated
schizophrenia
F20.4 Post-schizophrenic
depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified

The Criteria of
Diagnosis
2.
the presence of the symptoms
from at least two groups below
for one month or more:
e) the lasting hallucination of every form
f) blocks or intrusion of thoughts into the flow
of thinking and resulting incoherence and
irrelevance of speach, or neologisms
g) catatonic behavior
h) the negative symptoms, for instance the
expressed apathy, poor speech, blunting
and inappropriatness of emotional
reactions
i) expressed and conspicuous qualitative
changes in patients behavior, the loss of
interests, hobbies, aimlesness, inactivity,
the loss of relations to others and social
withdrawal

 Diagnosis of acute schizophorm

disorder (F23.2) if the conditions for
diagnosis of schizophrenia are
fulfilled, but lasting less than one
month
Diagnosis of schizoaffective disorder
(F25) - if the schizophrenic and
affective symptoms are developing
together at the same time

F20-F29 Schizophrenia, Schizotypal and Delusional

Disorders
F21

Schizotypal disorder

F22

Persistent delusional
disorders
Delusional disorder
Other persistent delusional
disorders
Persistent delusional
disorder, unspecified

F22.0
F22.8
F22.9
F23
F23.1
F23.2
F23.3
F23.8
F23.9

Acute and transient psychotic

disorders
Acute polymorphic psychotic
disorder with symptoms of
schizophrenia
Acute schizophrenia-like
psychotic disorder
Other acute predominantly
delusional psychotic
disorders
Other acute and transient
psychotic disorders
Acute and transient psychotic
disorder, unspecified

F20-F29 Schizophrenia, Schizotypal and Delusional

Disorders

F24
Induced delusional
disorder

F25
Schizoaffective
disorders
F25.0 Schizoaffective
disorder, manic type
F25.1 Schizoaffective
disorder, depressive type
F25.2 Schizoaffective
disorder, mixed type
F25.8 Other schizoaffective
disorders
F25.9 Schizoaffective
disorder, unspecified
F28
Other nonorganic
psychotic disorders
F29
Unspecified
nonorganic psychosis

F20.0 Paranoid Schizophrenia

Paranoid schizophrenia is
characterized mainly by
delusions of persecution,
feelings of passive or active
control, feelings of
intrusion, and often by
megalomanic tendencies
also. The delusions are not
usually systemized too
much, without tight logical
connections and are often
combined with
hallucinations of different
senses, mostly with hearing
voices.
Disturbances of affect,
volition and speech, and
catatonic symptoms, are
either absent or relatively
inconspicuous.

F20.1 Hebephrenic
Schizophrenia

disorganized thinking with blunted

and inappropriate emotions.
adolescent age, the behavior is
often bizarre.
There could appear mannerisms,
grimacing, inappropriate laugh and
joking, pseudophilosophical
brooding and sudden impulsive
reactions without external
stimulation. There is a tendency to
social isolation.

Usually the prognosis is poor

because of the rapid development
of "negative" symptoms,
particularly flattening of affect and
loss of volition. Hebephrenia should
normally be diagnosed only in
adolescents or young adults.
Denoted also as disorganized
schizophrenia

F20.2 Catatonic
Schizophrenia
Catatonic schizophrenia
is characterized mainly
by motoric activity,
which might be strongly
increased (hypekinesis)
or decreased (stupor),
or automatic obedience
and negativism.

We recognize two
forms:

COND
productive form which
shows catatonic
excitement, extreme and
often aggressive activity.
Treatment by
neuroleptics or by
electroconvulsive
therapy.

stuporose form
characterized by general
inhibition of patients
behavior or at least by
retardation and
slowness, followed often
by mutism, negativism,
fexibilitas cerea or by
stupor. The
consciousness is not
absent.

F20.3 Undifferentiated
Schizophrenia
Psychotic conditions
meeting the general
diagnostic criteria for
schizophrenia but not
conforming to any of
the subtypes in F20.0F20.2, or exhibiting
the features of more
than one of them
without a clear
predominance of a
particular set of
diagnostic
characteristics.
This subgroup
represents also the
former diagnosis of
atypical schizophrenia.

F20.4 Postschizophrenic
Depression

A depressive episode,
which may be prolonged,
arising in the aftermath
of a schizophrenic illness.
Some schizophrenic
symptoms, either
positive or negative,
must still be present but
they no longer dominate
the clinical picture.
These depressive states
are associated with an
increased risk of suicide.

F20.5 Residual
Schizophrenia
A chronic stage in the
development of
schizophrenia with clear
succession from the initial
stage with one or more
episodes characterized by
general criteria of
schizophrenia to the late
stage with long-lasting
negative symptoms and
deterioration (not
necessarily irreversible).

F20.6 Simple
Schizophrenia
Simple schizophrenia is
characterized by early and
slowly developing initial
stage with growing social
isolation, withdrawal,
small activity, passivity,
avolition and dependence
on the others.
The patients are
indifferent, without any
initiative and volition.
There is not expressed the
presence of hallucinations
and delusions.

F21 Schizotypal disorder

According to lCD-10 this
disorder is characterized
by eccentric behavior and
by deviations of thinking
and affectivity, which are
similar to that occurring in
schizophrenia, but without
psychotic features and
expressed symptoms of
schizophrenia of any type.

F22 Persistent Delusional

Disorders
Includes a variety of
disorders in which longstanding delusions
constitute the only, or
the most conspicuous,
clinical characteristic and
which cannot be
classified as organic,
schizophrenic or
affective.
Their origin is probably
heterogeneous, but it
seems, that there is
some relation to
schizophrenia.

F22.0 Delusional Disorder

A disorder characterized by
the development of one
delusion or of the group of
similar related delusions,
which are persisting
unusually long, very often
for the whole life.
Other psychopathological
symptoms hallucinations,
intrusion of thoughts etc. are
not present and are
excluding this diagnosis.
It begins usually in the
middle age.

F23 Acute and Transient

Psychotic Disorders

The criteria should be the

following features:
acute beginning (to two
weeks)
presence of typical
symptoms (quickly
changing polymorphic
symptoms)
presence of typical
schizophrenic
symptoms.

Complete recovery usually

occurs within a few
months, often within a few
weeks or even days.
The disorder may or may
not be associated with
acute stress, defined as
usually stressful events
preceding the onset by one
to two weeks.

F24 Induced Delusional

Disorder
A delusional disorder
shared
by two or more people with
close emotional links. Only
one of the people suffers from
a genuine psychotic disorder;
the delusions are induced in
the other(s) and usually
disappear when the people are
separated.

The psychotic disorder of the

dominant member of this dyad
is mainly, but not necessarily,
of schizophrenic type. The
original delusions of dominant
member and his partner are
usually chronic, either
persecutory or megalomanic.

F25 Schizoaffective
Disorders

Episodic disorders in which both affective

and schizophrenic symptoms are
prominent (during the same episode of
the illness or at least during few days)
but which do not justify a diagnosis of
either schizophrenia or depressive or
manic episodes.
Patients suffering from periodic
schizoaffective disorders, especially with
manic symptoms, have usually good
prognosis with full remissions without
any remaining defects.
They are divided in different subgroups:
F25.0 Schizoaffective disorder, manic type
F25.1 Schizoaffective disorder, depressive
type
F25.2 Schizoaffective disorder, mixed type
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified

Etiology of
Schizophrenia

The etiology and

pathogenesis of
schizophrenia is not
known
It is accepted, that
schizophrenia is the
group of
schizophrenias which
origin is multifactorial:
internal factors
genetic, inborn,
biochemical
external factors
trauma, infection of
CNS, stress

Genetics of Schizophrenia
Many psychiatric
disorders are
multifactorial
(caused by the
interaction of
external and
genetic factors)
and from the
genetic point of
view very often
polygenically
determined.

Genes x Environment
Development

Behavior
Emotion
Cognition
Perception

Schizophrenia susceptibility genes:

Current candidates

Whole genome linkage

1q,2p,5q,6p,6q,8p,10p,11q,13q,15q,22q

Expression profiling
RGS4 (1q) (four)*

Finer mapping

Functional candidates
COMT (22q) (eight)*
GRM3 (7q) (four)*
GAD 1 (2q) (four)*
CNRNA7 (15q) (two)*
PPP3CC (8p) (two)*

SNP association

Chromosomal
translocation
DISC1 (1q) (three)*
PRODH (22q) (two)

dysbindin (6p) (seven)*

neuregulin (8p) (six)*
G72 (13q) (three)*
MRDS1 (6p) (four)*

Akt1 (two)

* Number of positive samples

worldwide

Etiology of Schizophrenia Dopamine Hypothesis

The most influential and plausible are the
hypotheses, based on the supposed disorder of
neurotransmission in the brain, derived mainly from
1. the effects of antipsychotic drugs that have in common the
ability to inhibit the dopaminergic system by blocking action
of dopamine in the brain
2. dopamine-releasing drugs (amphetamine, mescaline,
diethyl amide of lysergic acid - LSD) that can induce state
closely resembling paranoid schizophrenia

Classical dopamine hypothesis of schizophrenia:

Psychotic symptoms are related to dopaminergic
hyperactivity in the brain. Hyperactivity of
dopaminergic systems during schizophrenia is result
of increased sensitivity and density of dopamine D2
receptors in the different parts of the brain.

Etiology of Schizophrenia
- Contemporary Models
Dopamine hypothesis revisited: various
neurotransmitter systems probably takes
place in the etiology of schizophrenia
(norepinephric, serotonergic,
glutamatergic, some peptidergic systems);
based on effects of atypical antipsychotics
especially.
Contemporary models of schizophrenia
conceptualize it as a neurocognitive
disorder, with the various signs and
symptoms reflecting the downstream
effects of a more fundamental cognitive
deficit:
the symptoms of schizophrenia arise from
cognitive dysmetria
concept of schizophrenia as a
neurodevelopmental disorder .

Etiology of Schizophrenia Neurodevelopmental Model

Neurodevelopmental model
supposes in schizophrenia the
presence of silent lesion in the
brain, mostly in the parts,
important for the development
of integration (frontal, parietal
and temporal), which is caused
by different factors (genetic,
inborn, infection, trauma...)
during very early development
of the brain in prenatal or early
postnatal period of life.
It does not interfere too much
with the basic brain functioning
in early years, but expresses
itself in the time, when the
subject is stressed by demands
of growing needs for integration,
during formative years in
adolescence and young
adulthood.

Structural changes in
brain

Hippocampus, amygdala,
parahippocamp.
Smaller in affected twin (static trait)
Disordered hippocampal pyramidal
cells
Also in entorhinal, cingulate,
parahippocampal cortex

Structural
changes in brain
Shrinkage of cerebellar
vermis
Thicker corpus callosum
Frontal lobes
Abnormal neuronal migration
in one study
Dendrites have fewer spines
But no major structural
abnormalities
Measures of frontal function
impaired

Mental disorders are brain disorders:

Loss of gray matter in childhood
schizophrenia

Functional changes in brain

Hypofrontality hypothesis
Discordant twins: low frontal
blood flow only in affected twin
Wisconsin card sorting task
Schizophrenics cant shift attn. to
other criterion
Functional imaging: frontal lobe
activity lower at rest, esp. in right
hemisphere, does not increase
during task.
Drug treatment increased
activation of frontal lobes

Treatment of
Schizophrenia
The acute psychotic schizophrenic
patients will respond usually to
antipsychotic medication.
According to current consensus we
use in the first line therapy the newer
atypical antipsychotics, because their
use is not complicated by appearance
of extrapyramidal side-effects, or
these are much lower than with
classical antipsychotics.

The newest medication is Invega

In general it may take up to 6 months for
medications to show consistent
effects

Atypical neuroleptics
Clozapine blocks 5-HT2A receptors > D2
As effective as typical neuroleptics on
(+) symptoms, more effective on (-)
symptoms
Fewer motor side effects (tardive
dyskinesia)
Actually increase DA release in frontal
cortex
L-DOPA can even be beneficial

 conventional antipsychotics
(classical neuroleptics)
chlorpromazine, chlorprotixene,
clopenthixole, levopromazine, periciazine,
thioridazine
droperidole, flupentixol, fluphenazine,
fluspirilene, haloperidol, melperone,
oxyprothepine, penfluridol, perphenazine,
pimozide, prochlorperazine, trifluoperazine
atypical antipsychotics
amisulpiride, clozapine, olanzapine,
quetiapine, risperidone, sertindole, sulpiride

Treatments
Psychotherapy - an adjunct to
meds and is very useful to keep
the patient on the meds.

Group therapy

Family therapy

Community support groups

 Early detection
and treatment
has the best
results/respons
e to treatment.
Per patients,
once you have
schizophrenia
you have it for
life. The best
you can hope
for is control.

 THANK YOU